1ฉุกเฉินไทยก้าวไกล อ.ศิริอร สินธุ

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1ฉุกเฉินไทยก้าวไกล อ.ศิริอร สินธุ

  1. 1.  Access Availability Affectionate Care Affordability
  2. 2. 
  3. 3.  Non-profit organization
  4. 4. 2. PPP(Public PrivatePartnership)architecture and performance ledto the following PPP (PublicPrivate Partnership)framework Government(Public)
  5. 5. 2. PPP (Public) Up to 95% ofexpenses byGovernmentcosts ofLeadership, Technology(Process, Medical
  6. 6.  Is not Charisma, Public Relations, Showmanship Is performance consistent behavior and trustworthiness Is Thinking, Doing and Communicating Is setting Direction, Aligning and Motivating Is creating an environment of continuous learning Learning doesn‟t end with school or college You must learn throughout you life - never cease to be a student
  7. 7.  Single toll free number „1-6-6-9‟ accessible on land and mobile phones
  8. 8.  Unique Emergency Response Center staffed with trained Communication, Medical and Police personnel
  9. 9.  Computer Telephony Integration Voice Loggers GIS / Maps GPS / AVLT Mobile Communication Application software for Sense, Reach and Care ePCR (Electronic Patient Case Record) Form
  10. 10.  Ambulance design based on best
  11. 11. ssssss
  12. 12.  Pre-hospital Care / Emergency Medicine Training in collaboration
  13. 13.  1 in 5 people visited the emergency department in 2007 (Centers for Disease Control and Prevention, 2010) Emergency care represents less than 3% of the nations $2.1 trillion in health care expenditures caring for 120 million annually Emergency physicians expect ER visits to increase with health care reform, due to growing physician shortages (ACEP, 2010)
  14. 14.  NPs in EDs for over 4 decades ◦ Emergency Departments ◦ Fast Tracks ◦ Urgent Cares NPs/PAs cared for 13% of all ED patients (Am J Emerg Med, 2005) New Models of Care ◦ Rapid Triage ◦ Rapid Exams ◦ Rapid Disposition
  15. 15.  2006 - Emergency Nurses Association embarked on Delphi Study (52 participants completed all three rounds) Competencies include knowledge, behaviors, and skills an entry- level NP should have in order to practice in emergency care. Competencies are intended to supplement the NONPF core competencies for all nurse practitioners as well as population- focused NP competencies NP practice may differ due to: ◦ variations in state regulation ◦ practice setting ◦ employment arrangement ◦ as a result of increases knowledge and/or experience
  16. 16.  2008 - Consensus Panel ◦ American Association of Colleges of Nursing (AACN) ◦ American Academy of Emergency Medicine (AAEM) ◦ American Academy of Nurse Practitioners (AANP) ◦ American College of Emergency Physicians (ACEP) ◦ American College of Nurse Practitioners (ACNP) ◦ American Nurses Association (ANA) ◦ American Nurses Credentialing Center (ANCC) ◦ Board of Certification for Emergency Nursing (BCEN) ◦ Commission on Collegiate Nursing Education (CCNE) ◦ Emergency Nurses Association (ENA) ◦ National Council of State Boards of Nursing (NCSBN) ◦ National Organization of Nurse Practitioner Faculties (NONPF)(In press: Nurse Practitioner Delphi Study: Competencies for Practice in Emergency Care. Journal of Emergency Nursing Sept 2010)
  17. 17. 
  18. 18.
  19. 19.  /
  20. 20.
  21. 21.  -
  22. 22.
  23. 23.
  24. 24.  EMS ( ) ” EMS ( )
  25. 25. 
  26. 26. 
  27. 27.  Procedure off line) procedure Procedure off line) Procedure on line)
  28. 28.  . ) . Scene size up) Triage) Dispatcher assessment) . ) . Primary survey) . Secondary survey) . Adjunct investigation with basic interpretation) CXR, CT, EKG, and Ultrasonography: FAST . Focus assessment) . Laboratories with interpretation) electrolyte, cardiac enzyme . (Initial diagnosis)
  29. 29. .. Life danger presentation) ). . Dyspnea. . Alternation of conscious. . Cardiac arrest & arrhythmia. . Shock. . Acute Coronary Symptom (chest pain). . Convulsion. . Anaphylactic. . Birth asphyxia
  30. 30. Organ danger presentation) ) Weakness Local severe pain High fever GI bleed Hemoptysis Hematuria Acute abdomen Complications of pregnancy Dehydration o Infant hypothermia Urgent condition) ). Hyperventilation. Electrolyte imbalance. Epitaxis. Drug addiction & withdrawal. Emergency psychosis
  31. 31. . ) . . . . manually triggeredventilators: MTV)(automatic transport ventilators: ATV)Noninvasive positive pressure ventilator(PEEP, BiPAP, CPAP) .
  32. 32.  “ ”
  33. 33.  “ ” “ ” “ ”
  34. 34.  ”
  35. 35.  “ ”
  36. 36.  “ ”
  37. 37.  ◦ ◦ ◦ ◦
  38. 38. ◦ ◦ ◦
  39. 39. ◦ ◦ ◦
  40. 40.
  41. 41.  ◦ ◦ ◦
  42. 42. 
  43. 43. Questions
  44. 44.  1. Triages patients‟ health needs/problems. 2. Completes specified medical screening examination. 3. Responds to the rapidly changing physiological status of emergency care patients. 4. Uses current evidence-based knowledge and skills in emergency care for the assessment, treatment, and disposition of acute and chronically ill and injured patients.
  45. 45.  5. Specifically assesses and initiates appropriate interventions for violence, neglect, and abuse. 6. Specifically assesses and initiates appropriate interventions and disposition for suicide risk. 7. Assesses patient and family for levels of comfort and initiates appropriate interventions. 8. Recognizes, collects, and preserves evidence as indicated
  46. 46.  9. Orders and interprets diagnostic tests. 10. Orders pharmacologic and non-pharmacologic therapies. 11. Orders and interprets electrocardiograms. 12. Orders and interprets radiographs. 13. Assesses response to therapeutic interventions. 14. Documents assessment, treatment, and disposition.
  47. 47.  15. Functions as a direct provider of emergency care services. 16. Directs and clinically supervises the work of nurses and other health care providers. 17. Participates in internal and external emergencies, disasters, and pandemics. 18. Maintains awareness of known causes of mass casualty incidents and the treatment modalities required for emergency care. 19. Acts in accordance with legal and ethical professional responsibilities (e.g., patient management, documentation, advance directives).
  48. 48.  20. Assesses and manages a patient in cardiopulmonary arrest. 21. Assesses and manages airway. 22. Assesses and obtains advanced circulatory access. 23. Assesses and manages patients with disability. 24. Assesses and manages procedural sedation patients. ◦ (See ENA/ACEP joint position statement – www.ena/org)
  49. 49.  25. Performs ultraviolet examination of skin and secretions. 26. Treats skin lesions. 27. Injects local anesthetics. 28. Performs nail trephination. 29. Removes toe nail(s).
  50. 50.  30. Performs a nail bed closure. 31. Performs closures (e.g., single layer, multiple, staple, adhesive). 32. Revises a wound for closure. 33. Debrides minor burns (e.g., non-adhering blister). 34. Incises, drains, irrigates, and packs wounds.
  51. 51.  35. Dilates eye(s). 36. Performs fluorescein staining. 37. Performs tonometry to assess intraocular pressure. 38. Performs Slit lamp examination. 39. Performs cerumen impaction curettage. 40. Controls epistaxis.
  52. 52.  41. Performs a needle thoracostomy for life- threatening conditions in emergency situations (e.g., tension pneumothorax). 42. Replaces a gastrostomy tube.
  53. 53.  43. Clinically assesses and manages cervical spine. 44. Performs lumbar puncture.
  54. 54.  45. Incises and drains a Bartholin‟s cyst. 46. Assists with imminent childbirth and post-delivery maternal care. 47. Removes fecal impactions. 48. Incises thrombosed hemorrhoids. 49. Performs sexual assault examination.
  55. 55.  50. Performs digital nerve block. 51. Reduces fractures of small bones. 52. Reduces fractures of large bones with vascular compromise. 53. Reduces dislocations of large and small bones.
  56. 56.  54. Applies immobilization devices. 55. Bivalves/removes casts. 56. Performs arthrocentesis. 57. Measures compartment pressure.
  57. 57.  58. Performs radio communication with prehospital units. 59. Interprets patient diagnostics as communicated by prehospital personnel. 60. Removes foreign bodies.
  58. 58.  Graduate Programs (Masters, Post " Masters, DNP) Programs with Emergency Concentration ◦ Uni of Southern Alabama – Mobile, AL ◦ Emory – Atlanta, GA ◦ Loyola – Chicago, IL ◦ Uni of Florida - Jacksonville, FL ◦ Uni of Texas, Houston, TX ◦ Uni of Texas, Arlington, TX ◦ Uni of Virginia – Charlottesville, VA ◦ Vanderbilt – Nashville, TN
  59. 59. Bednar, Susan; Atwater, Alison; Keough, VickiAdvanced Emergency Nursing Journal. 29(2):158-171,
  60. 60.  GRADUATE PROGRAM ◦ FNP Program – Consensus Model Document 2008  EDs require “family across the life span”  ACNP Program– usually no pediatric component CERTIFICATION ◦ FNP (e.g. ANCC, AANP)  AANP does not support the DNP equivalency exam – this is an academic degree not a “clinical” option ◦ Specialty Certification  BCEN Needs Assessment completed – to ENA BOD Summer 2010 for final recommendations (cert and/or portfolio) PREVIOUS EXPERIENCE ◦ Staff nurse (with BLS, ACLS, TNCC, ENPC) ◦ Certified Emergency Nurse (CEN) certified ◦ On-the-job training (e.g., suturing, minor procedures) ◦ Relevant continuing education
  61. 61.  Graduation from an accredited program ◦ Emergency concentration preferred FNP Certification Exam ◦ Specialty certification and/or portfolio option (TBA) ◦ Competency skills checklist (graduate program) Application Process ◦ Resume Submitted  RN License/NP License  Prescriptive Authority/DEA License Panel Interview – EDMDs/NPs/PAs and Staff Medical Staff Privileges – may take up to 6 mo
  62. 62. (n = 6279) NP – avg. 9 yrs NP experience Most Common Specialties ◦ FNP (54.5%) ◦ Adult (20.4%) Practice ◦ Community practice < 25,000 (17%) ◦ Communities of > 250,000 (39%) Settings ◦ Private physician practices (30.3%) ◦ Hospital-based outpatient clinics (11.6%) ◦ Hospital inpatient settings (9.8%) Goolsby, M.J. (2009) Journal of the American Academy of Nurse Practitioners, 21, 186–188.
  63. 63. RN/Tech (vital signs) NP/PA medically screens patient and then determines level (5-level triage) B. High risk situation is a patient you would put in your last open bed C. Resources: Count the number of differentA. Immediate life-saving intervention Severe pain is determined types of resources, not the individual tests or required by clinical observation x-rays (examples: CBC, electrolytes and coags (apneic, pulseless, severe respiratory and/or patient rating of equals one resource; CBC plus chest x-raydistress, SPO2<90, acute mental status greater than or equal to 7 equals two resources). changes, or unresponsive) on 0-1/distress is 0 pain scale SOME PATIENTS WILL BE MEDICALLY SCREENED ABCDs - TO ED and SENT TO THE FAMILY WAITING ROOM – NP/PA ASSESSES, INITIATE (e.g. UTI) THEN DISCHARGED ORDER SETS – TO FAST TRACK – THEN DISCHARGED
  64. 64.  Hospital vs. physician group role utilization Scope of practice (support to the physician with higher acuity patients) Resourcing of the role (add personnel to fast track) Ensuring medical staff at large is supportive and understanding of the role and scope of NPs/PAs. Compliance with medical staff oversight including Performance Improvement (PI) and Peer Review (PR).
  65. 65.  32 million newly insured Americans by 2014 Predicted 40,000 primary care physician shortfall by 2020 Not enough emergency medicine residency trained MDs (Academic Emergency Medicine, 2008) Market forces virtually guarantee that more health providers will be using NPs and other "physician extenders" (Bauer, 2010)
  66. 66.  The full integration of NPS... in many clinical areas will also enhance access. Decades of experience with NPs and several studies indicate that quality is not a problem with reforms that would allow NPs to provide more services. Patients like the care they receive from NPs at least as much as the care they receive from physicians. Consumers overall appreciation of NPs is extremely high. (Bauer, 2010; Edmunds, 2010; Office of Technology Assessment 1998; Safriet, 1992)
  67. 67.  Peer-reviewed journal articles reinforce the Office of Technology Assessments conclusions in 1981NPs can be utilized in a significant portion of medical services ranging from 25% in some specialty areas to 90% in primary care with at least similar outcomes. Collaborative, team-based approaches to care including teams led by NPs should be actively promoted to reduce overall spending on healthcare. NPs can reduce costs without diminishing quality in the process.(Bauer, 2010; Edmunds, 2010; Office of Technology Assessment 1998; Safriet, 1992)

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